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Based on observations during the facility walk through with the maintenance supervisor on 04/10/2013 the main fire alarm control panel had a red tag attached to the inside face of the panel. The red tag indicated that the fire alarm system was not in compliance with all requirements of NFPA 72, however it was not specific as to why it was "red tagged". The fire alarm system was tested during this walk through , by initating an alarm condition at a pull station and by activating a smoke detector in an operating room. In both situations the alarm sounded throughout the facility. However the facility needs to have a fire alarm specialist repair the fire alarm system to eliminate the red tag.

Based on observation during the facility walk through on 04/10/2013, with the maintenance supervisor and administrator, and discussions with the maintenance supervisor on 04/10/2013, there were several areas of the administrative suite (admin offices and conference room) that were not being served by a working air handler. The air handler for these areas was not working. All areas of the hospital shall be served by mechanical air supply/return and or exhaust systems.

Based on observations during the facility walk throughon 04/10/13, with the maintenance supervisor, the remote annunciator panels for the two (2) emergency generators were not functioning as noted herein;

a). The remote annunciator panel for the Onan generator was located at a central nurse station. When this generator was tested during the facility walk through on 04/10/13, with the maintenance supervisor, the annunciator panel had an alarm light which stated "low temp. alarm". Although the generator was functioning, the alarm condition shall be investigated by qualified personnel and corrections made to eliminate the alarm condition.

b). The remote annunciator panel for the Genrac generator was located at the PACU nurse station. During the facility walk through on 04/10/2013,, with the maintenance supervisor, it was observed that the annunciator panel was not functioning at all. This annunciator shall be repaired or replaced by qualified personnel to monitor the Genrac generator,

A). Based on observations during the facility walk through on 04/10/2013, with the maintenance supervisor, the ceiling area of the main corridor within the radiology suite, had signs of long running water leakage form the roof. The ceiling tiles were warped and showed signs of molding. A wall hung shelving unit just below the damaged ceiling tiles was warped and the preformed panels were splitting apart. The maintenance supervisor noted that the roof had been leaking for some time and that they had just not found the leak locations and had them sealed. The facility was now in the process of securing bids to have the interior ceilings repaired and the shelving unit removed.

B). Based on observations during the facility walk through on 04/10/2013, with the maintenance supervisor and the administrator, surgery room #3 smoke evacuation system was tested and found to be mechanically functioning but not as required by the Texas Hospital Licensing Rules. When the ceiling mounted smoke detector in the room was activated the low level return air grilles should have closed and a ceiling mounted exhaust grille should have opened to pull smoke laden air to the ceiling level and exhausted to the outdoors via a roof mounted exhaust fan. However in this test, the exhuast fan activated andn the supply ductwork was dampered to connect the low return ductwork/grilles to the exhaust system. Smoke would not be pulled to the ceiling level it would be pulled down to the floor level and exhausted through the low return air grilles.

Based on observations during the facility walk through with the maintenance supervisor on 04/10/2013 the main fire alarm control panel had a red tag attached to the inside face of the panel. The red tag indicated that the fire alarm system was not in compliance with all requirements of NFPA 72, however it was not specific as to why it was "red tagged". The fire alarm system was tested during this walk through , by initating an alarm condition at a pull station and by activating a smoke detector in an operating room. In both situations the alarm sounded throughout the facility. However the facility needs to have a fire alarm specialist repair the fire alarm system to eliminate the red tag.

Based on observation during the facility walk through on 04/10/2013, with the maintenance supervisor and administrator, and discussions with the maintenance supervisor on 04/10/2013, there were several areas of the administrative suite (admin offices and conference room) that were not being served by a working air handler. The air handler for these areas was not working. All areas of the hospital shall be served by mechanical air supply/return and or exhaust systems.

Based on observations during the facility walk throughon 04/10/13, with the maintenance supervisor, the remote annunciator panels for the two (2) emergency generators were not functioning as noted herein;

a). The remote annunciator panel for the Onan generator was located at a central nurse station. When this generator was tested during the facility walk through on 04/10/13, with the maintenance supervisor, the annunciator panel had an alarm light which stated "low temp. alarm". Although the generator was functioning, the alarm condition shall be investigated by qualified personnel and corrections made to eliminate the alarm condition.

b). The remote annunciator panel for the Genrac generator was located at the PACU nurse station. During the facility walk through on 04/10/2013,, with the maintenance supervisor, it was observed that the annunciator panel was not functioning at all. This annunciator shall be repaired or replaced by qualified personnel to monitor the Genrac generator,

A). Based on observations during the facility walk through on 04/10/2013, with the maintenance supervisor, the ceiling area of the main corridor within the radiology suite, had signs of long running water leakage form the roof. The ceiling tiles were warped and showed signs of molding. A wall hung shelving unit just below the damaged ceiling tiles was warped and the preformed panels were splitting apart. The maintenance supervisor noted that the roof had been leaking for some time and that they had just not found the leak locations and had them sealed. The facility was now in the process of securing bids to have the interior ceilings repaired and the shelving unit removed.

B). Based on observations during the facility walk through on 04/10/2013, with the maintenance supervisor and the administrator, surgery room #3 smoke evacuation system was tested and found to be mechanically functioning but not as required by the Texas Hospital Licensing Rules. When the ceiling mounted smoke detector in the room was activated the low level return air grilles should have closed and a ceiling mounted exhaust grille should have opened to pull smoke laden air to the ceiling level and exhausted to the outdoors via a roof mounted exhaust fan. However in this test, the exhuast fan activated andn the supply ductwork was dampered to connect the low return ductwork/grilles to the exhaust system. Smoke would not be pulled to the ceiling level it would be pulled down to the floor level and exhausted through the low return air grilles.